CHRONIC OBSTRUCTIVE PULMONARY DISEASE€¦ · Chronic obstructive pulmonary disease (COPD) is a persistent, progressive worsening of lung function ... Each person answers questions

CHRONIC OBSTRUCTIVE PULMONARY DISEASE (CHRONIC BRONCHITIS—EMPHYSEMA)

The impact on employers and employees

Introduction 1

Overview of COPD 3

Impact of COPD on the Workforce 9

Comorbidities of COPD 19

Resources and References 25

Table of Contents

With an estimated 24 million Americans displaying impaired lung function and only slightly more than 12 million diagnosed,1 COPD has become a significant problem for the national workforce. Employers face the growing challenge of workers with chronic obstructive pulmonary disease (COPD) now and in the future.

Most people with diagnosed COPD are younger than 65 years of age2 and are currently employed.3 Also, increasing numbers of adults older than 65 are employed and are expected to make up 6.1% of the workforce by 2016.4

Many people with COPD may be counted among your employees.

IntroductionTargeted COPD-management programs reduced gross medical costs 11% and saved 5% of healthcare expenses for the employing company.5

Introduction

11

Introduction

Chronic obstructive pulmonary disease (COPD) is a persistent, progressive worsening of lung function that may increase absenteeism, reduce productivity, and raise healthcare costs among working age adults.6-8 If COPD is managed appropriately—with early, accurate diagnosis and effective management strategies—its impact can be reduced.6 As an employer, you have the chance to make a difference.

This monograph outlines the personal, professional, and financial costs of COPD. The section titled, “Financial and Institutional Impact of COPD on the Workforce,” suggests steps that you can take to minimize the impact of COPD on your employees and your company.

Cost Burden of Chronic Disease for EmployersManaging chronic diseases—such as COPD—accounts for nearly 85% of all US healthcare expenditures.9

Management of Chronic Diseases Is a Key Driver of Increased Healthcare Costs

Much of your healthcare benefits are spent to manage chronic diseases. In 2010, an estimated 147 million Americans, the majority of whom were younger than 65 years of age, had at least one chronic disease.9

Chronic diseases affect 50% of the US population but account for 84% of all US healthcare expenditures and over three-fourths of private insurance spending.9

The Need Is ImmediateCOPD is an underrecognized, permanent, yet treatable, respiratory condition that affects 24 million US adults, over 9 million of whom are younger than 65 years of age.2 In 2010, COPD cost the US economy nearly $50 billion in healthcare expenses and lost productivity.10 In 2008 and 2009, chronic lower respiratory diseases were the third leading cause of death in the US.11,12

COPD diagnosis is often missed or delayed due to lack of awarenessnn Nearly 12 million US adults with impaired lung function are undiagnosed1

nn Diagnosis is often delayed because patients are unaware of the significance of their symptoms13

nn COPD may be misdiagnosed as asthma14

COPD is associated with poor physical and mental healthnn COPD is a progressive disease that worsens over time6

nn COPD limits physical activity and may lead to disability15

nn Exacerbations—bouts of more severe symptoms—may require hospitalization, especially when treatment is delayed or inappropriate16

nn COPD often coexists with other mental and physical medical conditions that compound patients’ health problems, increase their disability, and add to healthcare costs6,9

COPD is one of the most expensive health conditions for US employers17

nn Employees with COPD require more medical care and spend more healthcare dollars than other workersnn Absences, disability, and early exit from the workforce reduce employees’ productivity

Prevention and Improved Management of COPDCOPD is preventable, and the most effective prevention is to eliminate the leading cause of COPD—cigarette smoking. Another powerful preventive measure is to minimize workplace exposure to substances that damage the lungs.6

Employers have unique opportunities to provide educational programs and employee incentives that raise awareness of COPD and encourage effective disease management and prevention. Your company, in collaboration with healthcare plans, employer benefit consultants, or employer coalitions, can lessen the burden of COPD by implementing programs with proven effectiveness toward better employee health.5,18

The Rewards for Employers Are Potentially SignificantCOPD prevention, recognition, and disease management, when added to existing wellness programs, may result in a healthier, more productive workforce with less employee absenteeism and disability. Through targeted initiatives, your company may significantly reduce healthcare spending and productivity losses.

This monograph describes how you can contribute to your employees’ well-being, while helping your company to realize potentially significant savings. It also provides examples of effective programs that have lessened the impact of COPD in other companies and a list of resources to help you establish your own.

Overview of COPDBy the time patients seek medical help because of COPD symptoms, the underlying lung disease is usually well developed.6

Overview

of CO

PD

3

Overview of COPD

COPD is a permanent, progressive lung condition—chronic bronchitis and emphysema or both—that makes it hard to move air in and out of the lungs. People with COPD progressively lose their ability to function physically, professionally, and socially.

The cost of COPD is paid not only by the afflicted individual but also by his or her family, community, and employer. As one of the leading causes of disability and death, COPD exacts a high price from both individuals and American society as a whole.

For employers who support employees who have COPD or who have a family member with the disease, this section offers basic information about the disease, its causes, and its challenges.

COPD Is Chronic Bronchitis and EmphysemaCOPD results from constant lung inflammation, usually due to breathing irritating substances. The most common cause of COPD is cigarette smoke.6

Chronic bronchitis is a disease of the airways

In chronic bronchitis, irritants damage the lining of the airways, which narrows or constricts the breathing tubes making it harder to move air in and out of the lungs.1

Emphysema is a disease of the air sacs

In emphysema, exposure to irritants damages the air sacs. Exhaling requires more effort because the air sacs have lost their ability to spring back and small airways have collapsed. Because of the damage to the air sacs, less oxygen is transferred from the lungs to the blood.1

Causes of COPDMost people with COPD are current or former smokers. According to recent studies, 87% of American adults with diagnosed COPD are current or former smokers.19,20 Some people have a genetic susceptibility to COPD.6 Workers in some industries or in certain jobs have a greater chance of developing COPD.21

Both smokers and nonsmokers are more likely to have COPD if they inhaled irritants at work. Twice as many nonsmokers and 14 times as many smokers have COPD if they inhaled irritants at work compared with nonsmokers with no job-related exposure. Moreover, smoking alone, without work exposure to inhaled irritants, increases the chance of having COPD nearly 7-fold.19

You—as an employer—have the opportunity to provide programs to help your employees stop smoking and to provide clean air in a safe workplace.

4

COPD Is Diagnosed From Symptoms and Spirometry Test ResultsEmployers can help their workers with COPD obtain an early, accurate diagnosis and receive the appropriate treatment in a timely fashion.

COPD symptoms are often ignored

The initial symptoms of COPD are usually chronic cough and phlegm production. As the disease progresses, the patient becomes tired and short of breath and may have more frequent bouts of severe symptoms. Most patients seek medical care only after having a persistent cough and shortness of breath during activity; however, by that time, the underlying disease is often well developed.6

The COPD Population Screener™ (COPD-PS) helps patients identify their risk

You can help your employees identify COPD early in the disease by encouraging the use of the COPD Population Screener™ (COPD-PS), a validated list of 5 questions created by a panel of medical experts. Each person answers questions that rate his symptoms—frequency of breathlessness, coughs that produce mucus, and breathing problems that limit activity. Additional scores are given for the person’s age and smoking history. A person scoring 5 or more out of 10 is advised to seek medical attention.22

The COPD-PS, available online at www.copd.org/screening/survey, is an excellent tool for making employees aware of COPD symptoms, identifying patients in the early stages of COPD, and encouraging spirometry testing for an accurate diagnosis.22

Spirometry, an office-based test, is used to diagnose COPD

When healthcare professionals suspect COPD in adults with known exposure to inhaled irritants, especially in the presence of symptoms,6 the diagnosis should be confirmed by a spirometry test that measures the patient’s ability to move air in and out of the lungs.

COPD is treatable, but only partially reversible and usually worsens over time.6

Accurate and Timely Diagnosis of COPD Is CrucialPatients need an accurate and timely diagnosis of COPD to receive treatment. Unfortunately, a late or missed COPD diagnosis may delay treatment that lessens symptoms, reduces exacerbations—bouts of suddenly worsening symptoms—and improves the patient’s general health and ability to exercise.6 Because delayed diagnosis and exacerbations increase the medical cost of COPD and decrease productivity, early appropriate treatment may reduce an employer’s costs.6,23-25

COPD may be misdiagnosed as asthma

As many as 50% of patients with COPD are incorrectly diagnosed with asthma because both conditions restrict air flow.14 People who are misdiagnosed may receive inappropriate medications that increase the patients’ risk of pneumonia. They may also fail to receive appropriate education and rehabilitation.26 Healthcare professionals and patients need to be aware of the differences between COPD and asthma (Table 1) to avoid a costly misdiagnosis.6

Overview of COPD (CONT’D)

5

Table 1. Clinical features of COPD and asthma are different6

Feature COPD Asthma

Age of onset Mid-life Often in childhood

SymptomsSlowly progressive

Shortness of breath during exercise

Vary from day to day

Occur at night or early morning

Usual cause Long history of tobacco smoking An immune response to a stimulus (much like an allergy)

Airflow limitation Partially reversible Largely reversible

Response to bronchodilators or steroids

Small bronchodilator response to steroids

Large bronchodilator response to steroids

Adapted from: Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease [GOLD report]. Updated 2010. http://www.goldcopd.com.

COPD Management Includes Multiple ApproachesFor patients with COPD, effective disease management helps to improve exercise tolerance (ie, the ability to exercise a little bit longer) and the patient’s general health, prevent and treat complications and exacerbations, and possibly reduce mortality.6

Optimal treatment of most patients with COPD includes smoking cessation, medications, and pulmonary rehabilitation. For more severe cases, the patients may require oxygen therapy or surgery.

Patients often benefit from disease management programs involving teams of healthcare professionals.

Disease management programs benefit patients with COPD

Disease management programs offer systematic, multidisciplinary, long-term management of patients with chronic illness. Effective programs aim to manage the disease and prevent complications by encouraging adherence to medication, a healthy lifestyle, and attention to regular medical care.27 Patient counseling and education, and coordination and standardization of care are key components of successful programs.28

Disease management programs for COPD should provide processes for risk reduction, early diagnosis, patient assessment and monitoring, and the appropriate management of stable COPD and exacerbations. Effective COPD management aims to relieve symptoms, to improve exercise tolerance and health status, to prevent and treat disease progression, complications and exacerbations, and ultimately reduce mortality.6

In one example of a COPD management program, nurses trained in COPD monitored each case. Patient support included family consultations, physical rehabilitation, instructions on smoking cessation and adherence to therapy, as well as communications with the patient’s physicians.18 Patients who participated in the program for a year had a 77% reduction in work absences. There were also reductions in emergency department visits, hospital stays, unscheduled visits to physicians, and the use of antibiotics—all indications of fewer exacerbations.18

6

A review and analysis of COPD disease management programs—2 or more interventions managed by at least 2 healthcare professionals for 12 months or longer—demonstrated their benefits for patients with COPD.28 nn Better exercise capacitynn Reduced risk of hospitalizationnn Improved health status

The health benefit of disease management programs for employees with COPD may translate to productivity and financial benefits for employers.

COPD Is a Substantial Health BurdenThe health burden of COPD includes increasing disability, exacerbations, the presence of coexisting diseases, and early death. A patient’s physical decline affects all aspects of his or her life, including the ability to function as a productive employee.

Disability due to COPD worsens over time

Progressive muscle weakness and declining exercise capacity cause much of the disability associated with COPD.15,29 This physical decline limits the person’s ability to work as well as to participate in daily activities.15 COPD, more than other chronic conditions, restricts the type or amount of work that the afflicted person can perform.30

Exacerbations add to the COPD health burden and employers’ costs

COPD exacerbations—the sudden worsening of COPD symptoms—are most commonly caused by lung infections or air pollution.6

Treatments for exacerbations include oral corticosteroids to reduce inflammation and antibiotics for bacterial infections. Patients with severe or worsening exacerbations or with other serious medical conditions may require hospitalization or treatment in an emergency department.6

Exacerbations—tracked by the rate of hospitalizations, the use of prescription drugs, or both—have been reported at rates as high as 3 per year for each patient with COPD. However, approximately half of all exacerbations are not treated by a physician. That means that the rate of all exacerbations is undoubtedly higher.31

The frequency and severity of exacerbations increase with the severity of COPD.32 Each exacerbation negatively affects that patient’s overall health status, the clinical progression of COPD,33 and, consequently, the person’s ability to work.

One managed care organization found that patients who had exacerbations accounted for 80% of annual medical costs and nearly 60% of pharmacy costs for COPD.24 In another study, costs were higher when the initial treatment for an exacerbation failed.16

Patients who seek and receive prompt treatment for exacerbations have shorter recovery times, better overall health, and fewer hospitalizations.25 Therefore, prevention, early detection, and timely treatment of exacerbations help reduce the health and financial burden of COPD.6,32

Employers’ programs that help patients recognize and seek prompt treatment for exacerbations may increase employee productivity and save employer health costs.


7

COPD is a leading cause of death in the United States

In 2006, COPD was the fourth leading cause of all nonaccidental deaths in the United States, claiming nearly 121,000 lives. Since 2000, more women than men have died of COPD each year.2 Recent reports from the Centers for Disease Control and Prevention (CDC) list chronic lower respiratory diseases as the third leading cause of US deaths in 2008 and 2009.11,12 COPD accounts for more than half of all deaths due to lung disease.10

Among patients with COPD, the rate of cardiovascular death is nearly twice as high as that expected for people who do not have COPD.34

The Typical Patient With COPD Is a Working-Aged Man or Woman

COPD now occurs in adults of all ages and in more women than men

Traditionally, COPD has been viewed as a disease of older men. Today, the typical patient with COPD is likely to be a working-aged man or woman.

Nearly 80% of the 9.8 million US adults with known chronic bronchitis and nearly half of the 3.8 million adults with emphysema in 2008 were younger than 65 years of age. In addition, more women than men had chronic bronchitis or emphysema in 2008 (Figure 1).2 The rise in COPD among women is related, at least partly, to the increase in smoking among women after World War II.1

Figure 1. COPD affects men and women of all ages2

18-44 45-64 65 and older Men Women

7

6

5

4

3

2

1

0

Years of age

Mill

ions

of

per

sons

Chronic bronchitis Emphysema

Data are from the 2008 National Health Interview Survey.

Adapted from: Trends in COPD (chronic bronchitis and emphysema): morbidity and mortality. American Lung Association Web site. http://www.lungusa.org/finding-cures/our-research/trend-reports/copd-trend-report.pdf. Published February 2010. Accessed November 26, 2010.

Gender

8

Among 2129 participants in one disease management program, more than one-half of participants younger than 65 years of age were employed, and one-fourth were unable to work due to COPD.3

COPD Affects Employers as Well as PatientsCOPD places an increasing burden on the lives of patients, their families, and their employers as the disease progresses. Exacerbations and common comorbidities contribute to decreased quality of life, absences from work, reduced work productivity, and greater use of health resources, including hospitalizations.

Millions who suffer from COPD are currently in America’s workforce. This makes COPD an especially important disease for employers who provide healthcare insurance for active employees, as well as retirees. The next section details the impact COPD may have on your company.


Impact of COPD on the WorkforceIn 2010, the estimated direct and indirect costs associated with COPD approached $50 billion.10

COPD is a leading cause of lost productivity for US employers.17

Impact of C

OPD on the W

orkforce

9

Impact of COPD on the Workforce

COPD Decreases Employee ProductivityIn 2008, 12.1 million Americans—more than 3% of Americans aged 18 to 44 years, 7% aged 45 to 64 years, and 10% aged 65 years and older—had diagnosed COPD.2 The true prevalence of COPD is likely to be twice as high—24 million US adults—because many people with COPD are undiagnosed due to a failure to recognize their impaired lung function or an incorrect diagnosis of asthma.13,35 Therefore, a number of your employees are likely to have COPD or to care for someone with the disease.

As described in this section, the impact of COPD—decreased productivity and increased healthcare costs—is high for both employers and their employees.

Table 2. COPD decreases your company’s productivity and increases your company’s healthcare costs3

nn Absenteeism nn Short-term disability

nn Presenteeism* nn Long-term disability

nn Increased healthcare premiums nn Elevated turnover rate

* Presenteeism refers to productivity issues arising from employees who come to work despite illness or poor health.

Adapted from: Tinkelman D, Corsello P. Am J Manag Care. 2003;9(11):767-771 and Darkow T et al. J Occup Environ Med. 2007;49(1):22-30.

Absenteeism is higher for employees with COPD

Employees with COPD are more than twice as likely as their colleagues who do not have COPD to need either short-term or long-term disability leave (Figure 2). In addition, disability leaves taken by employees with COPD are longer than those for disabled employees without COPD (Figure 3). The average cost of lost productivity due to disability is $9815 for a disabled worker with COPD and $6335 for a disabled worker without COPD.7

Figure 2. COPD increases short-term and long-term disability7

Employees with COPD Employees without COPD

Any disability

25

20

15

10

5

0Short-term disability Long-term disability

Emplo

yee

s w

ith

dis

abili

ty c

laim

s (%

)

22

7

20.4

23

7

The percentage of the 1349 individuals with COPD in 2001–2004 who claimed disability while employed by 9 multistate companies was significantly (P<.0001) greater than the percentage of the 2696 employees of similar age, gender, geographic location, and employer, but without COPD.

Adapted from: Darkow T et al. J Occup Environ Med. 2007;49(1):22-30.

10

Figure 3. COPD increases the annual number of short-term and long-term disability days7

76.4

85.9

n=33 n=10

Employees with COPD Employees without COPD

Total disability days

Short-termdisability days

Long-termdisability days

100

80

60

40

20

0

Ave

rage

num

ber

of

days

of

dis

abili

ty p

er e

mplo

yee

(%

)

61.3

n=307 n=197

41.254.8

39.1

n=294 n=190

The average number of days of disability in a year is shown for disabled employees with or without COPD.


Presenteeism is higher for employees with COPD

Productivity may also be lost due to diminished on-the-job performance by employees who work despite poor health. Known as presenteeism, this reduced productivity can account for 56% of the cost of conditions labeled as breathing disorders, 14% of the cost of respiratory infections, and 62% of the cost of depression and anxiety.36 Workers with COPD report more absenteeism and presenteeism than expected for an average employee in a year.37 nn 19.4 more days absent from worknn 27.5 more days of presenteeism

Injuries and depression contribute to declines in work productivity due to COPD

Workers with COPD have significantly more sprains, strains, and fractures than do their colleagues who do not have COPD.7 These injuries may diminish your worker productivity.

COPD may also reduce productivity by negatively affecting workers’ mental well-being. In a survey conducted from 1998–2000, adults with COPD were nearly 3 times more likely to report symptoms of depression compared with adults with other chronic health problems.30 Even in the absence of COPD, depression is associated with an additional 12.4 absent days each year as well as poor job performance as judged by job-related accidents, injuries, and self-reported work failures.37

Impact of COPD on the Workforce (CONT’D)

11

COPD increases work-related disability

As COPD progresses and symptoms and functional impairments worsen, some people must restrict the type or amount of their work. In a survey of California adults aged 18 to 64 years, 29% of those with COPD limited their work activities. An additional 28% were unable to work. Compared with adults with no chronic health condition, people with COPD were 13 times more likely to reduce their work activities and 20 times more likely to be unable to work (Figure 4).30

Figure 4. COPD increases work-related disability30

Inability to work

35

30

25

20

15

10

5

0

Peo

ple

with h

ealth c

onditio

ns

(%)

Other chronic health conditions No chronic health conditions

COPD Asthma

Limitation in type or amount of work

28.7

10.111.4

2.0

28.1

7.59.2

1.2

The working-aged adults (18 to 64 years old) in the California Work and Health Survey conducted from 1998–2000 included 113 with COPD, 274 with asthma, 1354 with other chronic conditions, and 1502 with no chronic condition.

Adapted from: Eisner MD et al. Am J Public Health. 2002;92(9):1506-1513.

COPD-related employee illness and premature death reduce business productivity

COPD causes premature death and, consequently, lost US productivity.38 Diagnosed COPD in Americans of all ages cost the US economy an estimated $49.9 billion in 2010 (Figure 5). Hospital care accounted for the largest share of the $29.5 billion spent directly on medical costs for all Americans with COPD in 2010.10 Approximately 40% of the cost—$20.4 billion—was due to the indirect costs of premature death (mortality) and the cost of productivity lost due to illness (morbidity).10

12

Figure 5. High cost of COPD10

According to the NHLBI, the projected total costs for COPD in 2010 were approximately $50 billion

Total costs ($ billions)

Direct costsTotal=$29.5 billion

Indirect costsTotal=$20.4 billion

35302520151050

Home healthcare Nursing home care HCP

Prescription drugs Hospital care

Morbidity Mortality

1.3 3.7 5.5 5.8

8.0

13.2

12.4

HCP=healthcare professional; NHLBI=National Heart, Lung, and Blood Institute.

Adapted from: Morbidity and mortality: 2009 chart book on cardiovascular, lung, and blood diseases. National Heart, Lung, and Blood Institute Web site. http://www.nhlbi.nih.gov/resources/docs/2009_ChartBook.pdf. Published October 2009. Accessed November 20, 2010.

COPD Adds to Your Business CostsIn 1999, COPD ranked sixth among the most costly physical health conditions faced by 6 large US employers. Productivity losses due to absence and short-term disability accounted for 43% of health-related costs for eligible employees with COPD, but only 29% of costs for all physical health conditions of eligible employees (Figure 6).17 The good news is that effective programs designed to prevent or treat COPD may help cut those losses.


13

Figure 6. COPD leads to increased employee healthcare cost and lost productivity17

All Eligible Employees

$2505 71%

$703 20%

$316 9%

Eligible Employees With COPD

$37.24 57%

$22.62 35%

$5.21 8%

Medical Absence Short-term disability

A database of medical claims, disability claims, and absence records for 374,799 employees was analyzed for a 3-year period from 1997–1999. These individuals worked for 6 corporations located in 43 states.

Adapted from: Groetzel RZ et al. J Occup Environ Med. 2003;45(1):5-14.

Suboptimal COPD Care Increases CostsAccording to the National Committee for Quality Assurance (NCQA), quality healthcare can save lives and lessen the direct costs of medical care. In the 2009 NCQA report on the quality of healthcare offered by over 1000 health plans, the rate of spirometry testing to confirm a COPD diagnosis was only 39%. Bronchodilators were used at a rate of 78% and systemic corticosteroids at a rate of 66% in diagnosed COPD patients.39

Eighty percent of current smokers were told by their healthcare professional to stop smoking—the most effective way to prevent COPD—but only half received medical advice on strategies or medications for quitting.39 As discussed previously, prevention, early diagnosis, and appropriate treatment of COPD can limit the frequency of COPD exacerbations. Because exacerbations account for most of the medical costs of COPD,24 employers may realize cost savings by helping to improve the quality of their employees’ healthcare.

Healthcare reform sharpens the focus on improving quality and value

In addition to expanding healthcare coverage, the Patient Protection and Affordable Care Act requires healthcare plans to meet standards for access, resource utilization, quality, and patient information programs, among others.39 Prevention, wellness programs, and chronic disease management are considered essential components of healthcare benefits.40 Also, health plans must participate in quality incentive programs to qualify for health insurance exchanges.39

14

The concept of value-based insurance design (VBID)—reducing the cost of healthcare services in proportion to their clinical benefits—embraces disease prevention and management as ways to get more health for every healthcare dollar. For example, lower copayments for drugs that treat a chronic condition may increase patient adherence to therapy and reduce hospitalizations due to disease progression. One pilot program that waived copayment on diabetes drugs and provided education and support by telephone saved an average of $1300 in medical cost for each member during a 1-year period.41

In addition to reducing medical costs, VBID plans benefit employers by decreasing other expenses related to poor worker health. For one employer, lost productivity and wage replacement resulting from presenteeism and absenteeism accounted for 70% of health-related costs. Another company that focused on VBID programs designed to reduce employees’ health-related risk factors saved 2% of excess healthcare costs and 6% of the cost due to health-related losses in productivity.42

Employers can influence the quality of healthcare

Healthcare plans influence the quality of medical care.39 Your choice of a healthcare plan that offers value-based care for your employees with COPD may help retain a more productive workforce and may reduce your healthcare costs.

The remainder of this section examines the direct costs of US healthcare for COPD and identifies opportunities for employers to add value to their health benefits.

Costs Are Higher for Employed Americans With COPDIn an analysis published in 2008, the total healthcare costs for employees or their dependents with COPD were more than 4 times those for workers without COPD, with more money spent on office visits, emergency department visits, hospitalizations, and prescription drugs (Figure 7).8


15

Figure 7. Annual healthcare costs are higher for employees with COPD8

Outpatient costs

Emergencydepartment costs

Hospitalizationcosts

Pharmacycosts

7000

6000

5000

4000

3000

2000

1000

0

Ave

rage

cost

per

em

plo

yee

fo

r hea

lthca

re s

ervi

ce (

$)

$5848

$1829

$282 $57

$5336

$637

$2915

$948

Average Total AnnualCost per Employee $3634

Patients with COPD Patients without COPD

$15,875

COPD healthcare costs—claims to a single healthcare plan plus out-of-pocket expenditures—for workers aged 40–63 years or their dependents from January 2001 through December 2002 were analyzed for 17 multistate employers. Total annual healthcare costs, including costs of outpatient, emergency department or hospital care, and pharmacy use were all significantly (P<.001) higher for employees with COPD than for workers without COPD matched by age, gender, geographical location, and employer.


COPD Increases Healthcare Cost and UtilizationEmployer programs directed toward COPD prevention—and especially smoking cessation and reduction of workplace exposure to inhaled irritants—are key to reducing future medical costs of COPD.

COPD increases use of medical services

Even though only 4.4% of Americans have diagnosed chronic bronchitis and 1.7% have diagnosed emphysema,2 COPD was among the top 10 causes of hospitalization for reasons other than maternity or infant care in 2008.43 nn COPD was the primary diagnosis for 716,000 hospital discharges nn COPD was the secondary diagnosis for an additional 3,590,000 hospital stays

People with COPD are hospitalized for all reasons (especially for respiratory conditions) more often than people without COPD (Table 3).44

16

Table 3. COPD increases hospitalizations44

Reason for hospital stay Patients with COPD (% hospitalized)

Patients without COPD (% hospitalized)

Any cause 42.1 12.6

Respiratory cause 11.8 0.5

Data are from an analysis of 19,338 patients with COPD aged 45 years or older in a managed care organization in 2000–2001. Patients without COPD (n=94,384) who were enrolled in the same managed healthcare plan were of similar age and gender. Adapted from: Tinkelman DG et al. J Occup Environ Med. 2005;47(11):1125-1130.

In addition, COPD was the primary diagnosis for more than 1.5 million emergency room visits in 2000. Working-aged adults accounted for 64% of the emergency department visits for COPD (Figure 8).45

Figure 8. Nearly two-thirds of COPD-related emergency department visits are by working-aged adults45

≥75 y292,000

45–54 y194,000

65–74 y267,000

55–64 y315,000

25–44 y481,000

The number of US emergency department visits listing COPD as the first diagnosis was estimated from the National Hospital Ambulatory Medical Care Survey for 2000.

Adapted from: Mannino DM et al. MMWR Surveill Summ. 2002;51(6):1-16.


17

Early diagnosis and smoking cessation may reduce use of medical services

One way to reduce the cost of COPD is to identify the reasons for the high use of medical services. In one study, the number of office, emergency department, and hospital visits by adult smokers increased in frequency with the severity of COPD (Figure 9). Also, the average number of days each patient spent in the hospital each year increased from 1 for mild COPD to 5.5 for moderate COPD, and to 15 for severe COPD.46 These findings suggest that measures taken to reduce the severity of COPD may reduce the use of medical services.

Figure 9. Use of healthcare services increases with COPD severity46

7

6

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r

Outpatient visits Hospital visitsEmergency department visits

2.8

0.4 0.3

1.2

3.1

2.5

3.8

4.5

5.8

Mild COPD Moderate COPD Severe COPD

Patients with COPD, aged 35 to 80 years, with a history of smoking were treated at a single hospital from 1993–1994, then followed up for an average of 47 months. The graph depicts the use of healthcare facilities by 413 patients (209 with mild COPD, 114 with moderate COPD, and 90 with severe COPD) during the first year of follow-up. During 5 years of follow-up, use of each healthcare resource was significantly (P<.001) correlated with COPD severity.

Adapted from: Hilleman DE et al. Chest. 2000;118(5):1278-1285.

Exacerbations account for most of the direct medical costs of COPD

In one managed care organization, 80% of the annual medical costs and 56% of pharmacy costs for COPD were spent on the 47% of patients who experienced at least one exacerbation in 2006.24

Appropriate, early treatment of exacerbations may reduce COPD-related medical care. Failure of initial treatment for exacerbations in 2414 patients resulted in16: nn Relapse for 21% of patientsnn Hospitalization for 3.4% of patients nn A cost that was 3-fold higher than the average for treating exacerbations

18

Also, patients who do not report exacerbations to their primary healthcare practitioner are more likely to be hospitalized.25 Thus, timely and appropriate treatment of COPD exacerbations may save medical costs.

Employer programs designed to reduce the frequency of exacerbations may help to improve productivity and to reduce medical costs. Educating employees on the need to recognize exacerbations and to seek prompt treatment is essential for better employee health at a lower cost.

Undiagnosed COPD Increases Healthcare CostsThe cost of diagnosed COPD does not capture the full economic impact of the disease. In the year preceding a new COPD diagnosis, healthcare costs are higher, compared with expenses for similar people without COPD, due to23:nn 34% increase in costs for hospital stays and emergency department visitsnn 49% increase in the costs of office visitsnn 37% increase in pharmacy costs

Use of healthcare services was more than 50% higher for the 12-month period preceding the new COPD diagnosis. The dramatic rise in hospital stays and emergency department visits the month before a COPD diagnosis indicates that a number of patients are diagnosed only after an exacerbation.23

Employee education programs that alert your workers to the initial symptoms of COPD may lead to the early, accurate diagnosis of COPD, prevent an initial exacerbation, and save your company the cost of treating workers with more advanced disease.

Employers Can Help Manage the Cost of COPD Employers pay the price of lost productivity and more expensive health-related benefits due to COPD. With proper attention, however, some of this expense may be minimized or at least delayed. Timely diagnosis and proper treatment can ease the symptoms causing disability for many patients.

Prevention is the best medicine nn Programs that support employees’ efforts to quit smoking are the most effective way of reducing the medical cost of COPD. Providing a workplace free of smoke and other inhaled irritants also reduces the risk that your employees will develop COPD6

nn Alerting employees to the initial symptoms of COPD and providing a population screening questionnaire, such as the COPD-PS™, are effective ways to obtain an early diagnosis while the disease is still readily treated22,23

nn Engaging physicians in pay-for-performance programs encourages adherence to medical practice guidelines that recommend the use of spirometry to confirm a COPD diagnosis and the early use of bronchodilators to reduce symptoms and exacerbation frequency47

nn Encouraging patients to seek prompt medical attention for exacerbations can reduce the need for hospitalization and emergency department visits16,25

nn Providing access to disease management programs28 and pulmonary rehabilitation6 improves the health status and workplace productivity of employees with COPD

An investment in value-based health benefits for your employees with COPD is an investment in your workers’ health and your company’s productivity.


Comorbidities of COPDComorbid conditions compound the serious health problems of many patients with COPD, including working-aged adults.48-51

Com

orbidities of CO

PD

19

Comorbidities Increase the Burden of COPD for Employees and EmployersThe presence of comorbidities complicates medical treatment of patients with COPD and significantly affects their health and well-being (Figure 10). Additional medications needed to treat comorbidities increase the possibility that some treatment options for COPD or the comorbid condition must be discontinued because of drug interactions, side effects, or contraindications.6

Patients with comorbidities are likely to have more complications that require more office visits and hospitalizations.48-51 The additional medical monitoring and medications needed to treat comorbid conditions increase the cost of healthcare for patients with COPD.48

Figure 10. COPD comorbidities increase COPD burden for patients, healthcare practitioners, payors, and employers

�Complications

�Depression

�Disability

�Work absence

�Hospital stays

�Medications

�Physician visits

�Therapeutic options

�Compliance with therapy

Early death

More difficult diagnoses

COPD Comorbidities

Patients with COPD and comorbidities are less productive because of greater disability and more frequent hospitalization.49 Thus, employers’ costs increase due to more disability claims, higher healthcare costs, and ultimately more employee turnover as patients leave the workforce due to illness.

Fortunately, both COPD and its comorbidities can be managed.6 Actions taken by your company, as suggested in the previous section, may help achieve better outcomes for your employees and your company.

Comorbidities of COPD

20

Comorbid Conditions Are Common in People With COPDCOPD often develops in longtime smokers in middle age. This means people with COPD are more likely to have coexisting medical problems—comorbid conditions—that affect their physical and mental health. Having COPD may increase the risk for other diseases (Figure 11).6

Figure 11. Comorbid conditions occur frequently in patients with COPD6

Weight lossWeight lossWeight loss

Greater chance of other health problems



• High blood pressure • Lung cancer• Anemia—low iron in the blood• Heart disease and heart failure• Pneumonia• Weak bones

• Feeling sad or worried for a long time• Trouble sleeping• Diabetes or high blood sugar

Middle ageSmoking

Trouble breathing makes it harder to fix and eat healthy meals

Weak muscles make itharder to stay active

COPD

Adapted from: Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease [GOLD report]. Updated 2010. http://www.goldcopd.com.

Comorbidities of COPD (CONT’D)

21

Lung problems, cardiovascular conditions—diseases of the heart or blood vessels—and diabetes occur more frequently in employees with COPD than in their colleagues without COPD (Figure 12).8

Figure 12. Comorbidities are more common in employees with COPD8

60

50

40

30

20

10

0

Patien

ts (

%)

Infections

46

16

26

Asthma

2

14

45

Heartconditions

High blood pressure

21

37

Abnormallipids

21

32

7

15

None

37

1 or more


The occurrence of comorbid conditions was studied for workers employed by 17 larger US corporations who had healthcare claims in 2001–2002. The frequency of respiratory (lung), cardiovascular, and diabetes comorbidities in 6445 employees with COPD aged 40 to 63 years was compared to the occurrence of those comorbidities in 6445 employees without COPD matched by age, gender, geography, and employer. A significantly greater (P<.001) percentage of workers with COPD had each of these comorbidities compared with employees without COPD.


Working-aged adults with COPD have significant comorbidities

In one study, patients with COPD of all ages had higher comorbidity scores than patients with no COPD. Comorbidity scores were 6.7 times higher for patients with COPD aged 45 to 54 years and 4.4 times higher for those aged 55 to 64 years.44

Comorbidities Add to the Burden of COPDIn one review of published studies, cardiovascular disease and lung cancer were the leading causes of death among patients with mild or moderate COPD, whereas lung failure accounted for most deaths of patients with severe COPD.50

22

Cardiovascular diseases occur more frequently in people with COPD

A nationwide survey revealed that Americans 40 to 60 years of age who had COPD were 3 times more likely to also have cardiovascular disease—including stroke and diseases of the heart or blood vessels (Figure 13).49

Figure 13. Cardiovascular comorbidity is common in patients with COPD49


40

30

20

10

0

Patien

ts (

%)

16

6

12

4

15

5

11

2

12

29

Coronaryheart

disease

Myocardialinfarction

Congestiveheart failure

Irregularheartbeat

12

34

Poor circulationin legs

48

StrokeAngina

Of the 18,342 adults aged 40 years or older included in the 2002 National Health Interview Survey, 958 had COPD. Among those with COPD, cardiovascular diseases occurred more frequently.

Adapted from: Finkelstein J et al. Int J Chron Obstruct Pulmon Dis. 2009;4:337-349.

Compared with patients with either COPD or cardiovascular disease alone, a larger percentage of people with both COPD and cardiovascular disease visited emergency departments or physicians’ offices annually. People with both diseases also missed more days of work.49

Respiratory infections recur in most patients with COPD

COPD disrupts the natural defenses against bacterial and viral infections of the respiratory system. Repeated respiratory infections cause exacerbations, hasten the decline in lung function, and increase mortality.51

Diabetes increases the chance of hospitalization and early death in patients with COPD

COPD makes it harder for people with diabetes to get the exercise they need to help control blood sugar. Uncontrolled diabetes can damage the heart and blood vessels, as well as the kidneys, nerves, and eyes.52

Unfortunately, diabetes occurs more often in people with COPD and increases their chance of hospitalization and early death.53

Comorbidities of COPD (CONT’D)

23

Depression increases the burden of COPD

Depression and anxiety, often untreated or undertreated, are frequent comorbidities in patients with COPD. The coexistence of depression and COPD is associated with48: nn Increased COPD symptoms nn More physical disabilitynn Decreased adherence to treatmentnn Increased hospitalizationsnn Higher medical costs nn Early death

Weak muscles and bone disease decrease activity in patients with COPD

COPD makes it hard to stay active, and in some people, causes breathlessness while eating. Inactivity and poor nutrition may lead to a loss of muscle—even muscles needed to breathe—osteoporosis, and physical disability. This downward spiral further reduces exercise capacity, compromises overall health, and may cause an early death.54

Asthma may coexist with COPD

Nearly 1 in 5 people dying with COPD have a lifelong history of asthma.55 Having asthma along with COPD complicates the diagnosis of each condition and increases the risk of death.6,55

Sleep apnea—paused breathing during sleep—occurs in about 10% of people with COPD

Studies show that about 20% of patients with obstructive sleep apnea also have COPD, as well as other COPD-related comorbidities, including cardiovascular problems, diabetes, and metabolic syndrome.56

Anemia adds to low oxygen levels due to COPD

COPD reduces the amount of oxygen reaching the lungs and transferred to the blood, while anemia—a common problem for patients with COPD—limits the amount of oxygen that the blood can carry. Together, anemia and COPD decrease exercise capacity and may increase mortality.56

Resources and References

Resources and References

25

The following organizations can provide information for patients with COPD and employers about the condition and programs to minimize its impact.

Employer InformationThe Kaiser Family Foundation www.kff.org

American College of Occupational and Environmental Medicine www.acoem.org

CareContinuum Alliance www.carecontinuum.org

General COPD Information and Services—Government ServicesUS Centers for Disease Control and Prevention (CDC) www.cdc.gov/copd

National Institutes of Health Senior Health–COPD http://nihseniorhealth.gov/copd/toc.html

National Heart, Lung, and Blood Institute www.nhlbi.nih.gov/health/dci/Diseases /Copd/Copd_All.html

Agency for Healthcare Research and Quality (AHRQ) www.ahrq.gov

General COPD Information and Services— Independent OrganizationsCOPD Foundation www.copdfoundation.org

Global Initiative for Chronic Obstructive Lung Disease (GOLD) www.goldcopd.org

World Health Organization (WHO)—COPD www.who.int/respiratory/copd/en

General COPD Information and Services—Medical SocietiesAmerican Academy of Family Physicians (AAFP) www.familydoctor.org/706.xml

American Association for Respiratory Care (AARC) www.aarc.org

American Thoracic Society (ATS) www.thoracic.org

American Association for Cardiovascular and Pulmonary Rehabilitation (AACVPR) 1-312-321-5146 www.aacvpr.org

American College of Chest Physicians (ACCP) www.chestnet.org

Support and Advocacy for Patients With COPDCOPD International www.copd-international.com

US COPD Coalition www.uscopd.org

COPD EventsDrive4COPD http://drive4copd.com

World COPD Day http://www.goldcopd.com/WCDIndex.asp

Resources

26

1. American Lung Association. Lung disease data: 2008. http://www.lungusa.org/finding-cures/our-research/epidemiology-and-statistics-rpts.html. Accessed November 26, 2010.

2. American Lung Association. Trends in COPD (chronic bronchitis and emphysema): morbidity and mortality. http://www.lungusa.org/finding-cures/our-research/epidemiology-and-statistics-rpts.html. Published February 2010. Accessed November 26, 2010.

3. Tinkelman D, Corsello P. Chronic obstructive pulmonary disease: the impact occurs earlier than we think. Am J Manag Care. 2003;9(11):767-771.

4. Bureau of Labor Statistics. Older workers. Spotlight on Statistics, July 2008. http://www.bls.gov/spotlight/2008/older_workers/ Accessed April 11, 2011.

5. Zajac B. Measuring outcomes of a chronic obstructive pulmonary disease management program. Dis Manag. 2002;5(1):9-23.

6. Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease [GOLD report]. Updated 2010. http://www.goldcopd.com.

7. Darkow T, Kadlubek PJ, Shah H, Phillips AL, Marton JP. A retrospective analysis of disability and its related costs among employees with chronic obstructive pulmonary disease. J Occup Environ Med. 2007;49(1):22-30.

8. Darkow T, Chastek BJ, Shah H, Phillips AL. Health care costs among individuals with chronic obstructive pulmonary disease within several large, multi-state employers. J Occup Environ Med. 2008;50(10):1130-1138.

9. Anderson G. Chronic care: making the case for ongoing care. Robert Wood Johnson Foundation Web site. www.rwjf.org/pr/product.jsp?id=50968. Published February 2010. Accessed March 1, 2011.

10. Morbidity and mortality: 2009 chart book on cardiovascular, lung, and blood diseases. National Heart, Lung, and Blood Institute Web site. http://www.nhlbi.nih.gov/resources/docs/2009_ChartBook.pdf. Published October 2009. Accessed November 20, 2010.

11. Miniño AM, Xu J, Kochanek, KD. Deaths: preliminary data for 2008. Natl Vital Stat Rep. 2010;59(2):1-72.

12. Kochanek KD, Xu J, Murphy SL, Miniño AM, Kung H-C. Deaths: preliminary data for 2009. Natl Vital Stat Rep. 2011;59(4):1-68.

13. Yawn B, Mannino D, Littlejohn T, et al. Prevalence of COPD among symptomatic patients in a primary care setting. Current Med Res Opin. 2009;25(11):2671-2677.

14. Tinkelman DG, Price D, Nordyke RJ, Halbert RJ. Misdiagnosis of COPD and asthma in primary care patients 40 years of age and over. J Asthma. 2006;43(1):75-80.

15. Eisner MD, Iribarren C, Blanc PD, et al. Development of disability in chronic obstructive pulmonary disease: beyond lung function. Thorax. 2010. doi:10.1136/thx.2010.137661.

16. Miravitlles M, Murio C, Guerrero T, Gisbert R. Pharmacoeconomic evaluation of acute exacerbations of chronic bronchitis and COPD. Chest. 2002;121(5):1449-1455.

17. Goetzel RZ, Hawkins K, Ozminkowski RJ, Wang S. The health and productivity cost burden of the “top 10” physical and mental health conditions affecting six large U.S. employers in 1999. J Occup Environ Med. 2003;45(1):5-14.

References

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18. Tinkelman D, Corsello P, McClure D, Yin M. One-year outcomes from a disease management program for chronic obstructive pulmonary disease. Dis Manag Health Outcomes. 2003;11(1):49-59.

19. Blanc PD, Iribarren C, Trupin L, et al. Occupational exposures and the risk of COPD: dusty trades revisited. Thorax. 2009;64(1):6-12.

20. Celli BR, Halbert RJ, Nordyke RJ, Schau B. Airway obstruction in never smokers: results from the third National Health and Nutrition Examination Survey. Am J Med. 2005;118(12):1364-1372.

21. National Institute for Occupational Safety and Health. Work-Related Lung Disease Surveillance Report 2007. Morgantown, WV: National Institute for Occupational Safety and Health; 2008. DHHS (NIOSH) Publication No. 2008-143a.

22. Martinez FJ, Raczek AE, Seifer FD, et al. Development and initial validation of a self-scored COPD population screener questionnaire (COPD-PS). COPD. 2008;5(2):85-95.

23. Akazawa M, Halpern R, Riedel AA, Stanford RH, Dalal A, Blanchette CM. Economic burden prior to COPD diagnosis: a matched case-control study in the United States. Respir Med. 2008;102(12): 1744-1752.

24. Dalal AA, Christensen L, Liu F, Riedel AA. Direct costs of chronic obstructive pulmonary disease among managed care patients. Int J Chron Obstruct Pulmon Dis. 2010;5:341-349.

25. Wilkinson TMA, Donaldson GC, Hurst JR, Seemungal TAR, Wedzicha JA. Early therapy improves outcomes of exacerbations of chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2004;169(12):1298-1303.

26. Price DB, Yawn BP, Jones RCM. Improving the differential diagnosis of chronic obstructive pulmonary disese in primary care. Mayo Clin Proc. 2010;85(12):1122-1129.

27. Tiep BL, Carter R. COPD disease management. American Thoracic Society website. http://www.thoracic.org/clinical/best-of-the-web/pages/obstructive-disease/copd-disease-management.php. Accessed April 14, 2011.

28. Peytremann-Bridevaux I, Staeger P, Bridevaux P-O, Ghali WA, Burnand B. Effectiveness of chronic obstructive pulmonary disease-management programs: systematic review and meta-analysis. Am J Med. 2008;121(5):433-443.

29. Eisner MD, Iribarren C, Yelin EH, et al. Pulmonary function and the risk of functional limitation in chronic obstructive pulmonary disease. Am J Epidemiol. 2008;167(9):1090-1101.

30. Eisner MD, Yelin EH, Trupin L, Blanc PD. The influence of chronic respiratory conditions on health status and work disability. Am J Public Health. 2002;92(9):1506-1513.

31. Seemungal TAR, Hurst JR, Wedzicha JA. Exacerbation rate, health status and mortality in COPD— a review of potential interventions. Int J Chron Obstruct Pulmon Dis. 2009;4:203-223.

32. Hurst JR, Vestbo J, Anzueto A, et al. Susceptibility to exacerbation in chronic obstructive pulmonary disease. N Engl J Med. 2010;363(12):1128-1138.

33. Anzueto A, Leimer I, Kesten S. Impact of frequency of COPD exacerbations on pulmonary function, health status and clinical outcomes. Int J Chron Obstruct Pulmon Dis. 2009;4:245-251.

34. Huiart L, Ernst P, Suissa S. Cardiovascular morbidity and mortality in COPD. Chest. 2005;128(4): 2640-2646.

28

35. Hill K, Goldstein RS, Guyatt GH, et al. Prevalence and underdiagnosis of chronic obstructive pulmonary disease among patients at risk in primary care. CMAJ. 2010;182(7):673-678.

36. Schultz AB, Chen C-Y, Edington DW. The cost and impact of health condition on presenteeism to employers. Pharmacoeconomics. 2009;27(5):365-378.

37. Wang PS, Beck A, Berglund P, et al. Chronic medical conditions and work performance in the health and work performance questionnaire calibration. J Occup Environ Med. 2003;45(12):1303-1311.

38. Shavelle RM, Paculdo DR, Kush SJ, Mannino DM, Strauss DJ. Life expectancy and years lost in chronic obstructive pulmonary disease: findings from the NHANES III follow-up study. Int J Chron Obstruct Pulmon Dis. 2009;4:137-148.

39. National Committee for Quality Assurance. The state of health care quality 2010. www.ncqa.org/tabid/836/Default.aspx. Accessed May 5, 2011.

40. US Chamber of Commerce. Critical employer issues in the Patient Protection and Affordable Care Act. www.uschamber.com. April 26, 2010.

41. Fendrick AM. Value-based insurance design landscape digest. www.npcnow.org. Accessed May 5, 2011.

42. Fendrick AM, Jinnett K, Parry T. Synergies at work: realizing the full value of health investments. www.npcnow.org. Accessed May 5, 2011.

43. Agency for Healthcare Research and Quality. HCUP facts and figures: statistics on hospital-based care in the United States, 2008. http://www.hcup-us.ahrq.gov/reports/factsandfigures/2008/TOC_2008.jsp. Accessed November 15, 2010.

44. Tinkelman DG, George D, Halbert RJ. Chronic obstructive pulmonary disease in patients under age 65: utilization and costs from a managed care sample. J Occup Environ Med. 2005;47(11): 1125-1130.

45. Mannino DM, Homa DM, Akinbami LJ, Ford ES, Redd SC. Chronic obstructive pulmonary disease surveillance—United States, 1971–2000. MMWR Surveill Summ. 2002;51(6):1-16.

46. Hilleman DE, Dewan N, Malesker M, Friedman M. Pharmacoeconomic evaluation of COPD. Chest. 2000;118(5):1278-1285.

47. Discern. White paper and technical specification: pay-for-performance for COPD. Prepared for Boehringer-Ingelheim, September, 2009.

48. Maurer J, Rebbapragada V, Borson S, et al. Anxiety and depression: current understanding, unanswered questions, and research needs. Chest. 2008;134(4):43S-56S.

49. Finkelstein J, Cha E, Scharf SM. Chronic obstructive pulmonary disease as an independent risk factor for cardiovascular morbidity. Int J Chron Obstruct Pulmon Dis. 2009;4:337-349.

50. Sin DD, Anthonisen NR, Soriano JB, Agusti AG. Mortality in COPD: role of comorbidities. Eur Respir J. 2006;28(6):1245-1257.

51. Sethi S. Infection as a comorbidity of COPD. Eur Respir J. 2010;35(6):1209-1215.

References (CONT’D)

29

52. Centers for Disease Control and Prevention. National diabetes fact sheet: general information and national estimates on diabetes in the United States, 2007. Atlanta, GA: Centers for Disease Control and Prevention; 2008.

53. Mannino DM, Thorn D, Swensen A, Holguin F. Prevalence and outcomes of diabetes, hypertension and cardiovascular disease in COPD. Eur Respir J. 2008;32(4):962-969.

54. Chatila WM, Thomashow BM, Minai OA, Criner GJ, Make BJ. Comorbidities in chronic obstructive pulmonary disease. Proc Am Thorac Soc. 2008;5(4):549-555.

55. Meyer PA, Mannino DM, Redd SC, Olson DR. Characteristics of adults dying with COPD. Chest. 2003;122(6):2003-2008.

56. Barnes PJ, Celli BR. Systemic manifestations and comorbidities of COPD. Eur Respir J. 2009;33(5): 1165-1185.

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CHRONIC OBSTRUCTIVE PULMONARY DISEASE€¦ · Chronic obstructive pulmonary disease (COPD) is a persistent, progressive worsening of lung function ... Each person answers questions